Medicating the Mentally Ill

New York Times Editorial

Since last January, when Kendra Webdale was pushed in front of a Manhattan subway train by a man with a history of mental problems, politicians in Albany have been debating whether to make it easier to force people with mental illness to take their medication. Andrew Goldstein, the man accused of shoving Ms. Webdale to her death, had been repeatedly hospitalized for schizophrenia, but seemed to have a pattern of dropping out of his treatment programs and neglecting to take his medicine.

Now, Attorney General Eliot Spitzer has proposed legislation that would make it possible for courts to order some of the mentally ill to follow their outpatient treatment programs or face institutionalization. Proposing a new law in the wake of a widely publicized tragedy is such a knee-jerk reaction for politicians that Spitzer's bill deserves special scrutiny. But the idea has real merit.

The bill would apply only to people who have been hospitalized due to a failure to follow a treatment program. When such patients are released, hospitals or caregivers could apply to the court for a special order requiring that they take their medication and follow their outpatient program. Petitioners would have to demonstrate that the patients' history showed a particular danger that they would fail to take care of themselves, and that their conditions were serious enough to justify court supervision. If patients ignored an order and failed to take medication, caregivers could ask that they be recommitted to the hospital for re-evaluation.

Civil libertarians worry that such a law could be used to force medication or commitment on someone with borderline mental problems. Spitzer and the Legislature must be sensitive to those concerns. But they must also listen to families of the mentally ill who too often see their loved ones' refusal to take medication lead to recurrent psychotic symptoms. The result of that sort of tailspin is seldom the kind of violence that led to the Webdale tragedy. But it almost always takes a terrible toll on the patient, the family and the community. That was just the pattern described last week by the parents of a man shot while brandishing a sword on a commuter train. He had been repeatedly treated for mental problems but failed to follow through on his outpatient care. If the Legislature can make it easier to avoid these crises, it should act promptly.

New York Times Editorial Sunday, April 11, 1999

NYC; Subway Push, And a Sister Feels a Chill

The New York Times May 4, 1999,

By CLYDE HABERMAN

KIM WEBDALE had no sooner boarded an uptown No. 6 train at 23d Street one evening last week when the conductor announced that they would be going nowhere for a while. Someone had fallen ill at the 51st Street station, or so the conductor said.

“To be perfectly honest,” said Ms. Webdale, a health-education consultant who had been on her way home from work, “the first thing that went through my mind was that there was another person pushed to the tracks.”

Her instincts, unfortunately, were perfect.

Edgar Rivera of the Bronx had just lost his legs after being shoved in front of a train at 51st Street. His attacker, the police said, was a homeless man with a history of mental illness, Julio Perez. It was not really startling that Ms. Webdale, 34, had intuited the truth.

Four months ago, at the 23d Street stop on the N and R lines, her younger sister’s name was added to the thick catalogue of big-city horrors when she, too, was pushed to the tracks as a train pulled in. Kendra Webdale, 32, died on the spot. And her accused attacker turned out to be another troubled man, Andrew Goldstein, who had stopped taking the medication that kept his schizophrenia under control. “I was horrified and devastated that this happened again,” Kim Webdale said of the latest subway nightmare.

“But even though I was shocked, I was not surprised,” she added. “Nothing has changed. We have thousands of unmedicated, untreated people living in New York, and many are living in the subways. I’m in the subways on a regular basis, and nothing is being done about these people.”

High on the list of what she would like to see done is a New York State law authorizing involuntary treatment for mental patients whose condition has sadly deteriorated because they refuse to take the drugs that help keep them functioning on the street. Most states have such laws, in one form or another. Generally, they permit the forced treatment of mental patients long before they slip so far from reality that they kill someone. But not New York, where the standard is to wait until the mentally ill are deemed threats to themselves or others.

You could argue, and civil liberties absolutists do, that these people have the same right as anyone else to control their lives, that to force treatment on them would bring back the awful snake pits of the past. You could also argue, and some do, that passing a law in the emotional wake of a tragedy is not always wise.

But two disastrous subway pushings in four months have a way of forcing the issue. As for civil liberties, some psychiatrists note that many schizophrenics cannot recognize how ill they are. The freedom they enjoy, these doctors say, is the freedom to sleep in doorways and eat out of garbage cans. Typically, they are menaces to themselves, not others.

“IT’S ludicrous how we now require people to become dangerous before we can offer care,” said D. J. Jaffe, a New Yorker who is on the board of the Treatment Advocacy Center, a group that supports a law authorizing involuntary treatment. Like Mr. Jaffe, many on the group’s board have mentally ill relatives, and they are frustrated at their inability to get help for people who clearly need it.

Several bills are bouncing around in Albany, but the one that treatment advocates favor has been put forth by the State Attorney General, Eliot L. Spitzer. It would allow judges to order mentally ill people who have been hospitalized in the past to take their drugs while out on their own, or face being recommitted for treatment. The request for such an order could come from a patient’s family. But the ultimate decision would rest with a judge, who would first have to hear expert testimony that the patient is not likely to survive on the outside without supervision. There are enough built-in checks, the bill’s supporters say, to guarantee that only those desperately needing help are affected; the aim, they insist, is not to sweep the streets of nuisances.

It makes sense to Kim Webdale, who recalled how, for weeks after her sister’s death, she could not bring herself to go into the subways. But slowly, and cautiously, she went back. Sometimes, she lays flowers where Kendra died. “I feel constant sadness,” she said. “It’s a constant loss.” And all she wants is that no one else ever feels such pain for a sister so pointlessly killed.

To the Editor:

In light of the recent subway “pushing” -- allegedly by Julio Perez, a mentally ill man (news article, April 30) -- New York should join other states and adopt a “grave disability” standard for involuntary hospitalization of the mentally ill. In order to meet this standard, a person has to have reached such a state of neglect that he has no ability to provide for his basic human needs. To meet New York’s current criterion, “danger to oneself and others,” a person has to actually threaten severe physical harm to himself or others. A change in the wording of the law would not solve the problem of the many mentally ill people roaming our streets, but would be a small step in the right direction.

CYNTHIA MATTHEWS

New York, April 30, 1999

NY Times Op-ed

NY TIMES January 7, 1999

Real Help for the Mentally Ill

By SALLY L. SATEL

Whenever a mentally disturbed person turns violent, a search for blame begins. In the few days since 32-year-old Kendra Webdale was pushed to her death under a Manhattan subway train and a schizophrenic man named Andrew Goldstein was charged with the crime, advocates for the mentally ill have blamed Gov. George Pataki for failing to re-invest the savings from de-institutionalization in community mental health services, as he promised. Others have blamed the de-institutionalization of people with problems like Mr. Goldstein’s in the first place.

The problem is that the debate tends to be polarized: law-and-order conservatives want people permanently locked up, and nurturing liberals want more community-based services and housing but bridle at restrictions on patients’ personal liberties. Society, meanwhile, must find a way to handle the thousands of severely mentally ill people who function quite well when on medication but who become violent, homeless or profoundly delusional when not being treated.

Some states have had success with “outpatient commitment” programs for patients like Mr. Goldstein who have a history of circulating through hospitals, halfway houses and clinics. Under this system, a court orders a person to follow a course of treatment, which usually includes anti-psychotic medications, while living in the community. The patient is carefully supervised, and if he does not comply, the police can be called -- by a parent, doctor, group-home manager, for example -- and the patient hospitalized against his will. The system is intended for patients with records of poor cooperation with treatment.

Several states with outpatient-commitment statutes have had success. In Iowa, North Carolina, Ohio and the District of Columbia, admissions to psychiatric wards were cut by half to two-thirds. Patients know they’ll go back to the hospital if they don’t participate in treatment. For some (even those who have previously failed to cooperate with intensive supervision), this leverage is the key. The only study that failed to find outpatient commitment effective in reducing admissions, one on Tennessee’s program, noted that medical workers were not vigorously enforcing the law. No surprise. Without teeth, outpatient commitment is meaningless.

In 1994, the New York Legislature, not yet ready to pass a statute, created an outpatient-commitment pilot program out of Bellevue Hospital. The project was to determine whether court-ordered treatment would reduce hospital stays for severely mentally ill people who had a habit of stopping medication with disastrous results.

Last month, the encouraging results were made public: patients in the program spent six weeks, on average, in the hospital compared with 14 weeks for those not ordered. Considering that the court-mandated group had more patients who also had substance abuse problems, a definite risk for hospitalization, the results are more impressive. A number of the patients told the researchers that they complied with treatment was because they didn’t want to be committed.

A hearing sponsored by the city and the New York State Office of Mental Health was held on Dec. 16 to help determine the next step when the project expires in June. Dozens of people testified. Some were patients in the program or parents of participants. Also present was the civil liberties lobby, predictably complaining that the involuntary commitment of patients violates their rights. If we only had a better, more caring mental health system, this argument goes, then patients would cooperate without arm-twisting. What the critics refuse to acknowledge is that about half of all schizophrenics have no insight into their own condition and no understanding of why they need medication. As for free will, the freedom to be psychotic is no freedom at all.

New York State, which has an estimated 227,000 seriously mentally ill adults, should put a statute on the books that allows outpatient commitment. It might help avert tragedies like the one this week.

Sally L. Satel is a psychiatrist who works in a methadone clinic in Washington.

Following are some letters to the editor written in response to the above op-ed:

NY Times Letters this Sunday

January 10, 1999

To the Editor:

Sally L. Satel (Op-Ed, Jan. 7) is correct when she says that the debate as to how to treat mentally disturbed people becomes polarized with the occurrence of tragic incidents like the death of Kendra Webdale under a Manhattan subway train. Dr. Satel urges New York State to enact a law that allows for involuntary outpatient commitment, to lead to greater compliance with
treatment by chronically recalcitrant patients. Civil liberties advocates are concerned that such involuntary commitments would violate patients' rights.

Some adults need outside authorities to set limits on their actions. There will always be a tension between the need to enforce the social rules and the need to be vigilant, protecting the citizenry's
civil liberties.

LEON HOFFMAN, M.D.
New York, Jan. 7, 1999

The writer is chairman of the American Psychoanalytic Association's committee on public information.

To the Editor:

My heartfelt appreciation goes out to Dr. Sally L. Satel (Op-Ed, Jan. 7) for stating the outstanding value to be derived by long-term, "noncompliant" psychiatric patients from Bellevue Hospital's involuntary outpatient treatment program. As the parent of a son who after 23 years in the revolving door of decompensation, hospitalization and release was chosen for the pilot program, I feel fortunate to know that he is receiving the personal attention and regular
medication he needs to live independently and remain unhospitalized.

At the Dec. 16 public hearing on the program, I appealed to the seemingly misguided civil libertarians to walk in my and my son's shoes before prejudging this concept. The Legislature would strike a humane blow by expanding mental health law to include involuntary outpatient commitment.

MELVIN R. SILVERMAN
New City, N.Y., Jan. 7, 1999

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The following appeared in Satufday's NY TIMES 3/6/1999.

To the Editor:

Re Jean Arnold's Mar. 2 letter criticizing New York's Attorney General Eliot L. Spitzer's proposal that would allow courts to order mentally ill people to take their medication:

Since most people with schizophrenia accept treatment, there would be no need to monitor large numbers of them, only those who fail to show up for treatment like Andrew Goldstein, who pushed Kendra Webdale in the subway. In New York, court-ordered outpatient treatment for tuberculosis
patients has proven very effective in lowering the disease rates.

Outpatient treatment could be equally effective in increasing compliance and lowing the incidence of violence among people with schizophrenia. That is why the Attorney General's proposal is supported by groups that want safer streets and those that care about the mentally ill.

D. J. JAFFE
New York, March 3, 1999

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